Wiki 20610 Denying for Assistant Surgeon Modifier??

[lgraham@ospc1579.com]

Has anyone else had this issue with CPT 20610 (specifically Anthem) denying a claim or retracting payment due to no assistant surgeon modifier when it is used for a steroid in office injection by a PA? I have spoke to the insurance & they refuse to send claim back as the modifier is missing & my provider rep said to appeal. I have almost (10) claims that a retraction for this is occurring. Claims are from 2022 & 2023 retracted. There is no pattern as it is so random that it is happening but only between (2-4) patients.

 

[iowagirl77]

Are you billing under the PA? I believe Anthem requires you to bill under a supervising physician, not a PA, so that could be the actual issue instead of a modifier.

 

[amyjph]

Did you compare to a sample of other claims to the same payer, timeframe, and CPT(s) to see how many you have and if others were paid? If you are ortho there should be a big # to look into.
Is it only ten out of how many? Does it have something to do with the PA on the claim, is it the same PA on every one. Is there something else possibly wrong with the claim and maybe it's an incorrect takeback? Did you check everything about the demographics and coding of the claims? Just ideas; sometimes the denial or rejection does not make sense and could be wrong.
You are 100% sure it is for no AS/81?
Do the patients all have an Anthem plan from the same employer or state? Is it a Medicare Advantage plan or commercial? It depends on the state as to if you can submit under the PA/NP NPI or it has to be under the supervising MD. Does your state allow injections by a PA (practice act). Was US or fluoro involved?